Mailbag #10: With Dr. Helen Feltovich

In this mailbag episode of Healthful Woman, Dr. Nathan Fox and Dr. Helen Feltovich answer your top questions. They address questions regarding bilobed placenta, appropriate activity levels for someone with a history of PPROM, whether an MFM doctor is needed following IVF, and more.

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Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OB-GYN and maternal fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy and wellness.

All right. So I got Helen Feltovich in the hot seat here. We just recorded a podcast which probably dropped, I don’t know, a week or two weeks or whatever ago. And I told her just today that I’m gonna be doing a mailbag podcast. Helen, thanks for agreeing to this.

Dr. Feltovich: I’m terrified.

Dr. Fox: You don’t know any of the questions that are coming. This is not, you know, this is not, as I said before, like, quiz show where we gave Van Doren the answers in advance. This is like…Do you even know the reference for that?

Dr. Feltovich: No.

Dr. Fox: You were busy dressing windows instead of watching movies in the ’90s. All right.

Dr. Feltovich: Trimming. Trimming them.

Dr. Fox: Trimming. Oh, that’s right.

Dr. Feltovich: And by the way, just for everybody to know, I wasn’t actually asked about this in a way that I agreed. I was just told this was happening. So there is that minor…

Dr. Fox: No, and that’s what we mean by asked. Told by someone else.

Dr. Feltovich: That’s true. That’s true.

Dr. Fox: What I’m gonna do, since you’re new to this format, I’m gonna read the question and we’re gonna talk about our thoughts on the answer to our listener’s questions. As if someone asked you as an obstetrician, as a maternal fetal medicine specialist, as a human being, what are your answers. First question is from Haya [SP]. I’m 30 weeks pregnant with my third and was diagnosed with a bilobed or almost succenturiate placenta, with a marginal cord insertion at my 20-week anatomy scan. My OB seems very unbothered and calm about it and Google is being very unhelpful as usual. I’m curious if you would discuss what this is and if there’s anything to worry about. She has a second question. I also had a vanishing what looks like identical twin at about six-ish weeks and I’m wondering if that smaller attached lobe on my placenta can come from that. I haven’t seen any research available on that. Thank you, Haya. So first, Helen, how do you explain to people what is a bilobed placenta and a marginal cord insertion and whether you should be unbothered like Haya’s OB or bothered like Google is by these findings.

Dr. Feltovich: Dr. Google is bothered by everything.

Dr. Fox: Yes, Dr. Google is definitely a pessimist.

Dr. Feltovich: Dr. Google is a pessimist and full of lots of information. The answer is unbothered. So a bilobed…about all of those things, the bilobed part, the possible succenturiate part and the marginal cord insert. This has changed recently for people like us, Natey. We used to get all bothered by marginal cord inserts now before, but recent evidence has suggested it’s not a big deal. I always look again because you want to make sure that as the placenta develops, it doesn’t wind up being velamentous, which means it’s in the membranes, which is a whole different thing, that you don’t have, Haya, so don’t worry about it. But that is very, very rare.

Bilobed just means that instead of your placenta, like, all the cotyledons, all the functioning, so the placenta being together in one sort of, like, half moon shaped mound, you have two separate parts of it that are connected by membranes in the middle. And sometimes, the cord can come out of the membranes in the middle. That’s rare. And that’s not what you have because that’s not a marginal cord insert. The marginal cord insert just means that the cord isn’t coming out, like, pretty much smack in the middle or around that area. And succenturiate is a different version of that where I don’t know how you think of this, Natey, but to me, bilobed is more, they’re sort of equal lobes and you may or may not see the cord coming out from the center. And succenturiate just mean there’s a little island over here that certainly wouldn’t have a cord on it that’s just sort of over there.

Dr. Fox: In my brain, I think about it as bilobed as sort of, like, classic picture of two cherries…

Dr. Feltovich: Double.

Dr. Fox: …sitting next to each other. Whereas a succenturiate is more like the earth and the moon. There’s a big placenta, then like a little satellite placenta off to the side.

Dr. Feltovich: A little one over there.

Dr. Fox: And honestly, functionally as far as we know, there’s really not a risk of anything.

Dr. Feltovich: NBD. NBD.

Dr. Fox: No big deal?

Dr. Feltovich: No big deal.

Dr. Fox: Yeah. And then, I tell people the only real issue if there’s a bilobed or succenturiate placenta is please make sure the obstetrician knows…

Dr. Feltovich: Pulling it off.

Dr. Fox: …that when you deliver and the placenta comes out, all the lobes come out. Because otherwise, you’re gonna be coming back to do it again several weeks later. So that’s really, again, marginal cord where it’s not plunking into the bulls eye but more marginal. Not such a big deal as well. So yeah, I agree…

Dr. Feltovich: Just don’t pull it off. It’s a little easier to pull it off during the delivery. But even if you do that, meh.

Dr. Fox: We can go get it.

Dr. Feltovich: Just get it.

Dr. Fox: So Fox and Feltovich agree with your obstetrician. Not such a big deal. And we will differ with Google on this one. Now tell me about the vanishing or vanished twin that Haya asked about in the second part of her question.

Dr. Feltovich: Yeah. Also NBD.

Dr. Fox: Good.

Dr. Feltovich: I want to take a moment and just acknowledge that pregnancy loss is hard. It’s easy for people to think it’s not a big deal when you lose a pregnancy so early, especially if it’s a twin pregnancy, because you’ve got another one that’s ongoing. So I just want to take a moment to acknowledge that that can be painful in pregnancy and acknowledge your emotion around it. That said, it is not a big deal at all from the standpoint of your ongoing pregnancy and there is, I can think of no pathophysiological possible path to having a bilobed placenta because of that there.

Dr. Fox: Right. And especially when Haya was saying that her twin were identical. And if was identified early as identical, that means there’s only one placenta anyway. So that wouldn’t really do it. Yeah, I mean, the idea of a term is a vanished twin, which is sort of an odd term, but it sort of means there was a twin, and then the second was gone, vanished like magic. But essentially what it means is you have…

Dr. Feltovich: It sounds scary.

Dr. Fox: …yeah, you have a twin pregnancy and either before you see two heartbeats or after you see two heartbeats, at some point there’s only one ongoing baby. The other one, either the heartbeat stopped or it never developed. And if that were to happen later in pregnancy, we don’t typically call it a vanished twin. You’d either call it a IUFD, like, a fetal demise of one of the twins. There’s different ways we describe. The vanished twin typically to us implies it happened very early in pregnancy, like in the first trimester, under 10 week, under some gestational age that people probably disagree on. But…

Dr. Feltovich: And has no effect on…

Dr. Fox: Right. And if it’s early, really has no effect. There are some studies, I think, that showed possible, like, risk of, like, growth restriction, probably a lot of this because a lot of these pregnancies were IVF. And so, it’s hard to know if it’s really it. But yes, I agree. If I happens earlier, there is, for many people, sort of a moment of sadness because they were sort of excited about having twins at first, now it’s not. Or they learned about this the day they found out. Like, they thought it was one, then they come in. So it’s two, but it’s really only one, and then there’s sort of, like, confusion about how do you feel about that. And for some people who either medically feel twins is not a good idea for them or just they were not really ready for twins, for some people potentially it’s a relief that they don’t have to worry about that in the same way. So there’s a lot of different emotions that happen…

Dr. Feltovich: So many emotions.

Dr. Fox: …ranging. Yeah.

Dr. Feltovich: Yeah. I think it’s easy to get a bit of disenfranchised grief around that and just a surprise, hey, there were two, but now there’s only one. But in terms of safety to Haya and her baby…

Dr. Fox: Should be fine.

Dr. Feltovich: …right now, NBD.

Dr. Fox: All good. All right.

Dr. Feltovich: Fox and Feltovich agree again.

Dr. Fox: Unbelievable. All right. Here’s the next one. This is definitely a topic I’m interested in and I assume you are too. From Anna. Here we go. I’m currently 22 weeks pregnant with a history indicated McDonald cerclage…

Dr. Feltovich: Here we go.

Dr. Fox: …due to 22-week PPROM in my last pregnancy. My question is regarding activity and exercise that is safe to do during my pregnancy. My MFM did not put me on bedrest and said besides not standing or walking excessively, had no activity restrictions. But he says there is no data to guide me on what precisely “excessive” is. As a result, I am limiting my standing and walking because I do not want to contribute to PPROM and I do not know where the line is. But my health would likely be better if I could go on walks or do a lot of exercise. How should I think about balancing this and can someone please do an RCT, randomized control trial, where women with cerclages have monitored exercise so we can get some data to guide us. Thank you. That’s from Anna. Good question, huh

Dr. Feltovich: That’s a great question and it’s the question, Anna, that people like Natey and I are asked by every single person who has a cerclage. And we agree with your MFM that there aren’t great data to guide us. That said, there are way better data these days than there has been in past, you know, past years and decades. For instance, when I trained, if a person had a cerclage, what you have is called a history-indicated cerclage. That means that something in your pregnancy history has inspired the recommendation for you to have a cerclage in this pregnancy. There are also ultrasound-indicated cerclages, right, maybe for a short cervix. Or exam-indicated cerclage for a cervix that is dilated.

Dr. Fox: Or feels like an egg.

Dr. Feltovich: Or feels like an egg. Feels like a very soft-boiled egg. That’s right. But in answering your question about activity level, the really great news about today is that we know from growing evidence, both that being active is healthy and, you know, remember rather old days, Natey, where we would say, you know, “You shouldn’t start an exercise program in pregnancy,” like, that’s too much. And then, we would say, “Well if you’re, like, at this level of activity before you get pregnant and you want to continue it, that’s fine.” And now we’re like, get thee to the gym, you know. So all of that has really changed. And you kinda nailed it, Anna, when you said, “It’s not healthy for me to be limiting my activity.” You are absolutely right. Obviously for you, it is not healthy. Some people feel like, and this is exactly what I say to patients, Natey, maybe you’re exactly the same. If whatever you’re doing makes you feel better, then do that. And for some people, being, like, limiting their activity, given that we don’t have any real data, some people may feel that limiting their activity is something that they can do to improve their outcome. And that might feel good. We would absolutely not recommend bedrest. That, we know, is just straight up dangerous. We didn’t know that five years ago but we know it now. But for other people…

Dr. Fox: I think we knew it five years ago.

Dr. Feltovich: Did we?

Dr. Fox: That bedrest was dangerous.

Dr. Feltovich: Didn’t that come out, like, right before the pandemic? Well, it is 2024, isn’t it?

Dr. Fox: Yeah.

Dr. Feltovich: Wow, I’m getting old. Okay, yeah. Well, when I started training, we didn’t know that. And for other people, they feel much better and are much healthier if they are not limiting their activity. So bottom line is whatever makes the person feel least anxious, you know, what’s good for the goose is good for the gander, right? So whatever makes the mother least anxious is also going to be, I think, the best for the baby.

Dr. Fox: Yeah. I’m very, very similar. Essentially I agree, Anna, with your MFM. The data’s terrible so we don’t know for certain. But it’s also very hard to study, even you did that randomized control trial, because it’s probably different for different people. It’s probably not something that on average is the right thing to do for everyone, number one, like what Helen was saying, there’s the mental aspect of it. So for some people, rest will make them feel better. For other people, rest will make them feel worse. And vice versa. And it’s probably different. Everyone’s uterine activity is going to be different and sort of how it responds to activity. So what I typically tell people is, I don’t recommend bedrest and I don’t recommend training for an Ironman. Right? So those are very far apart from each other. In the middle is very gray and I believe that probably each person falls somewhere within that gray in a different place and I get very hokey and say, listen to your body.

Dr. Feltovich: Me too.

Dr. Fox: So be active and if doing something causes contractions, cramping, pressure, back off. And if you feel fine doing it, it’s probably fine.

Dr. Feltovich: Or extreme shortness of breath.

Dr. Fox: Yeah. But if you feel fine doing it, it’s probably fine. And again, the same thing, I tell people the same thing. If you are gonna feel better, say, doing a little bit more, I’m gonna take a two hours a day and put my feet up because great, God bless. That’s fine as long as you’re not doing complete bedrest. So we’re aligned as they say, as the kids say, “We’re aligned.”

Dr. Feltovich: Fox and Feltovich together again.

Dr. Fox: Love it.

Dr. Feltovich: One little tiny note of hope for the future about that, Anna, though, is that that’s exactly what our lab collaborative is trying to address. Because what you’re really saying is what sort of biomechanical changes could happen in my body to cause, you know, a 22-week delivery and that’s exactly what people like us and others are trying to figure out. And fun fact, unpublished fact. Only for Natey’s podcast.

Dr. Fox: Okay, hot take. Here you go.

Dr. Feltovich: Listeners to know. So we did, I think I mentioned our research and the podcast that we had. And we looked at normal, so persons undergoing normal pregnancy. We scanned all kinds of maternal anatomy features. So we did, you know, serial scans of the uterus. We did transvaginal scans to look at the cervix and the lower uterine segment. We did these in both laying down and standing up positions. And just a really small group of people, this was at Intermountain in Provo. And then, the data was sent to Columbia, and they made fancy models out of it. And fascinatedly, there was no difference in the…

Dr. Fox: I know exactly what you’re gonna say.

Dr. Feltovich: …what am I gonna say?

Dr. Fox: That standing up doesn’t put anymore pressure on the cervix. It also makes sense because anatomically…

Dr. Feltovich: Exactly.

Dr. Fox: …it pushes the uterus down on an L shape so probably closes the cervix by standing up.

Dr. Feltovich: Bingo.

Dr. Fox: It’s like stepping on a garden hose.

Dr. Feltovich: Yep. It’s like stepping on a garden hose. Yep. Exactly right. Which is at least presumably also what a cerclage does. It changes the forces on the cervix. And so, it was such a small subset and we’ve never published it. We probably should because it’s really interesting. But for the first time, when I reviewed those data, I was like, the stress forces on the internal [inaudible 00:15:54] are no different standing up or laying down. This is why bedrest doesn’t matter.

Dr. Fox: Right. Right. It’s true. All right. Awesome. Anna, great question. All right. Next one is from Mary. And this is a name that you and I can’t pronounce properly. Mary. Two Midwesterners trying to figure this out. All right. My family makes so much fun of me for this. I apologize to all of you east coasters out there. All right. So Mary. Here we go. Thanks for this amazing podcast.

Dr. Feltovich: My mother’s name was Mary, so I say it right. Mary Margaret.

Dr. Fox: Oh, God bless you. Thanks for this amazing podcast. Exclamation point. I really enjoy it. Another explanation point.

Dr. Feltovich: It should be a double one after that.

Dr. Fox: Someone that went through IVF, should they go to an MFM just because they became pregnant through IVF? If everything is going well in their pregnancy, should they still be going to an MFM? Thank you.

Dr. Feltovich: That is a great question and I would pitch a question right back to Mary, which is related to Anna’s question actually. How do you feel? And how much do you like the person? Like, if you have a wonderful MFM like Natey, probably you want to stay with that person because you like them. But if you have a cranky MFM, like I don’t know, me, then you might want to just continue with the person that you get your regular gyn and obstetrical care for. The truth is that there’s a lot of, I mean, this sort of gets at the heart of the question of what is a high risk pregnancy versus a low risk pregnancy. And I tend to sorta steer people away from those kinds of labels because when people think of themselves as high risk, that feels scary, I think. And, you know, Natey, you’ve heard patients say this all the time too. You know, sometime patients will say, “Oh, my gosh, I went from low risk to high risk in an instant and that was terrifying and what does this mean?” So I kinda steer away from these labels. It is true that people who have undergone IVF have a little tiny higher risk of having a birth defect. And therefore, you would be very wise to get a full detailed ultrasound with an MFM. But beyond that, who do you like? Who do you want to be with? How do you define yourself? That’s my answer.

Dr. Fox: It’s so interesting. Just yesterday, someone asked me, it was a very similar question but not because of IVF but I think they were 40 or something like that. And they said, you know, “Are we a high risk pregnancy? Or we a low risk pregnancy?” And I said to them, “Which would you like to be?”

Dr. Feltovich: Exactly.

Dr. Fox: I always ask that. I say, “Would you like to be high risk?”

Dr. Feltovich: Fox and Feltovich aligned again.

Dr. Fox: Some people want to be…I want people to know that this is serious stuff. Fine. You’re high risk pregnancy. And if they’re like, “No, I feel great.” Like, fine, you’re low…and I tell people, the analogy I use is I say, “Risk is like height.” I’m 5’11”. Am I tall? Well, maybe. I mean, if I’m standing in a kindergarten class, I’m very tall. But if I’m standing in an NBA locker room, I’m very short. And so, risk is the same way. So sure, an IVF pregnancy has more risk than all things being equal, a non-IVF pregnancy. But it has way less risk than if you were carrying twins or at hypertension or diabetes or whatever it is.

Dr. Feltovich: A million different things.

Dr. Fox: Right. And so, you know, and sometimes I like to tell people where they rank in my waiting room. Top of the food chain. you’re bottom of the…and so, it’s really one of those things. And ultimately, risk is also not about the person being high risk or the pregnancy being high risk. It’s what are you at risk for? So an IVF pregnancy, sure there’s a risk for a slightly increased risk, again, not to scare people, but a slightly increased risk of birth defect.

Dr. Feltovich: Very tiny. Yeah.

Dr. Fox: So okay. You get an advanced ultrasound but you don’t need to have your delivery by an MFM because of that. So you’re slightly increased risk maybe of preeclampsia or something. All right. Do whatever, take a baby Aspirin. You get washed…like every obstetrician. But you’re not at an increased risk of a lot of other things. And so, it really you have to focus on if there’s an increased risk, for what. And as long as that’s being followed correctly, either by your OG or maybe by an MFM periodically, like, for an ultrasound, then it should be fine. And, you know, around the country, most MFMs don’t do obstetrical care and deliver babies. Most MFMs, you know, hang out and do ultrasounds and consults and maybe some procedures.

Dr. Feltovich: I would actually say it’s half and half.

Dr. Fox: I thought it was 70/30 who didn’t.

Dr. Feltovich: You know what?

Dr. Fox: Last census.

Dr. Feltovich: We should look that up because I thought it was 70/30 and now it’s more almost close to half and half because of the MFM, you know, movement and things like that.

Dr. Fox: All those youngsters doing deliveries.

Dr. Feltovich: Yeah, they’re loving it.

Dr. Fox: Either way, let’s say it’s half and half. So it’s not…so for some people, there isn’t even an option to have full care and delivery by an MFM, which is usually fine. Okay.

Dr. Feltovich: Yeah, because we all go to OB-GYN school, and then the only things that MFMs do that are extra is ultrasound training and some critical care training.

Dr. Fox: And research.

Dr. Feltovich: And research. Yeah. So otherwise, we’re all the same. So, you know, who do you like? That informs your pregnancy care.

Dr. Fox: Love it.

Dr. Feltovich: Who do you want to be? I like this analogy about the height because I always say, you know, on that continuum, I always say, you know, “I can’t define risk for you. That’s a very personal thing and it’s kind of a moving target.” And I use the analogy of how long is a piece of string. And people always look at me confused. So now I’m gonna start saying, “I’m 5’9” because that…thank you.

Dr. Fox: You could also use religion. There’s always someone more religious than you. There’s always someone less. Always. There’s only two people on earth…

Dr. Feltovich: That’s true.

Dr. Fox: …who don’t have someone more or less religious than them.

Dr. Feltovich: Who are they?

Dr. Fox: The most religious and the least religious. That’s it. Everybody else is in the middle.

Dr. Feltovich: I’m like, do you know them? How interesting. Let’s get them on the podcast.

Dr. Fox: I may know the one who’s all the way the least…no. All right. Great. Next question is from…

Dr. Feltovich: Thank you, Mary.

Dr. Fox: …yeah. Next one is from Jackie. Hi, Dr. Fox and I will add Dr. Feltovich. I listened to your podcast on early pregnancy loss and you mentioned a few different scenarios but noted that if you see a heartbeat and viable pregnancy in the uterus and ultrasound, the risk of miscarriage reduces drastically. I recently had this happen to me where I went in for an ultrasound because I had light bleeding at seven weeks. Ultrasound and blood test confirmed that everything was normal and on track. But then, the next day I miscarried. If there was a heartbeat, then what was bleeding? Did something in the body cause the miscarriage? Example, an issue with the placenta. I am curious what is actually happening in that situation versus a situation where heartbeat is seen and the patient has no bleeding or symptoms. Note, I had a subchorionic hematoma my first pregnancy that resolved. Could these outcomes be related? So basically, Jackie, I’m sorry you lost the pregnancy. Obviously that’s hard. It is true that the risk of miscarriage is much lower if we see a heartbeat on ultrasound, but it’s not zero. And so, the question is…

Dr. Feltovich: It’s never zero.

Dr. Fox: Yeah. Never.

Dr. Feltovich: Even all the way.

Dr. Fox: So why would someone have bleeding and lose a pregnancy after seeing a heartbeat and everything looking fine at seven weeks?

Dr. Feltovich: Because you’re looking early, as opposed to later. And we don’t know how to define where we are in the process. And that’s why the only thing we have to offer is reassurance that the pregnancy loss normal at this moment and counseling about the reasons to come back. I do want to mention that there’s nothing wrong with your body. So if that’s what the question is, why did you do okay with your first pregnancy and then not this one, there’s nothing wrong with your beautiful body. It can make babies just fine and that’s one thing that it seems like patients are always in danger of trying to figure out what they did and lay these things on themselves. And it wasn’t that. As I’m sure you went over on your podcast about early pregnancy loss, the most common reason is that there’s something chromosomally matter, the chromosomally the matter with the little embryo that is causing it and its placenta not to grow and develop appropriately. And, you know, Natey, I don’t know if you ever really reflect on this but sometimes when I think about all the DNA divisions that have to happen properly for someone to come out semi-normal, like you and me…

Dr. Fox: Semi.

Dr. Feltovich: …semi, emphasis on the semi. But other people are probably, like, straight up normal. I don’t know. It’s kind of astonishing to me that any of us ever get here.

Dr. Fox: I tell people that all the time.

Dr. Feltovich: It’s crazy.

Dr. Fox: I say that the crazy thing is that it ever works out. Not that it doesn’t work out from time to time.

Dr. Feltovich: Exactly.

Dr. Fox: It is miraculous. It’s crazy.

Dr. Feltovich: I was gonna say it’s a miracle, like a literal miracle.

Dr. Fox: I agree. I think that, like you said, in the first trimester, the overwhelming majority, not 51%, but the overwhelming majority of miscarriages are due to something that’s normal in the embryo from day one. You just don’t know it. And it is true that most of those that are genetically abnormal will miscarry before there’s a heartbeat. And that’s why when you see a heartbeat, the likelihood is reduced. Now there are still many pregnancies that will miscarry after there’s a heartbeat that are genetically abnormal. And is, that is probably the most likely reason. Sometimes even if we test the chromosomes, they are normal but that’s really just the tip of the iceberg. And so, the depth of genetic abnormalities that’s possible is way, way, way greater than what we typically would even test if we checked on a first trimester miscarriage. So I would say…

Dr. Feltovich: Right. And the breadth of what really can go wrong genetically, we’re just scraping the surface of. I mean, we don’t know what we don’t know. So even if we do a super deep dive and, you know, even if we were to look at every single thing in an embryo or a fetus’ genome…

Dr. Fox: We would still not know.

Dr. Feltovich: …we may still not know because we don’t know what we don’t know. Growing all the time. Anyway, not your fault.

Dr. Fox: Definitely not.

Dr. Feltovich: Bottom line.

Dr. Fox: Definitely not. All right. Our last question for today for this mailbag podcast, is from Sarah. Hi. Thank you for your wonderful podcast. I’d like to submit a question for the mailbag.

Dr. Feltovich: How many exclamation points on that one?

Dr. Fox: Well, this is more of a formal writing so…

Dr. Feltovich: Oh, I got it. Okay.

Dr. Fox: So Sarah, I could use an exclamation point, but…

Dr. Feltovich: I mean, next time.

Dr. Fox: …okay. That’s fine. I’m not offended or anything like that. All right. I’m currently 32 years old and I have five health children. My pregnancies were uneventful other than being diagnosed with gestational diabetes during my last pregnancy at age 30, which remained under control. Around a week after my last delivery, I was feeling very short of breath and my BO recommended I go to the emergency room where I was diagnosed with peripartum or postpartum, it’s PP cardiomyopathy.

Dr. Feltovich: Cardiomyopathy.

Dr. Fox: I am being monitored by HF, I assume heart failure, and PP cardiologists, I assume peripartum cardiologists, with a slow but steady increase in my EF, ejection fraction. My doctors have told me that I’ll likely need to be on medication for life. I’d like to understand what causes this condition. Does the risk increase with every pregnancy or if one’s pregnancies are in close succession. I guess hers were. Is it possible for me to ever be totally cured? How would this impact future pregnancies? Thanks in advance for addressing this topic. So this is a big topic and…

Dr. Feltovich: Big topic.

Dr. Fox: …this is a tough situation. So Sarah, I hope you continue to recover. This is no joke. Cardiomyopathy is a big deal. So Dr. Feltovich, talk a little bit about peripartum cardiomyopathy.

Dr. Feltovich: So I wish I had one of my obstetric cardiology friends here next to us because they could address this more. But I will tell you the good news…boy, I must be getting old because I keep comparing today with how things were like when I started. I distinctly remember the first patient that I saw with peripartum cardiomyopathy because the cardiologist came. Her ejection fraction was terrible, 25%. And they said, “This is awful. You’ll be on medication forever and you should never have another baby.” And it was her first baby actually. And she was early 30s. So, you know, none of the typical risk factors, genetic ones, I’m sure. And I thought, oh, this is bad. This woman might not even live and whatever else. Six months later, she was off all of the medications and doing great. Her ejection fraction had returned to normal within two weeks and she was doing great.

I remember that patient because while it is, well, full disclosure, I am not a cardiologist. But it does seem from my cardiology colleagues that we co-manage these patients with, that the outlook today is much better than previously thought. And in fact, postpartum cardiomyopathy probably happens a lot more frequently than we think and we don’t realize it. And I know, I’m searching my brain right now, but I know that there’s some really interesting research going on in the space of, is it the fibroblast or? You know, like, actual heart inflammation and heart muscle cells looking at cardiac remodeling…

Dr. Fox: The myocites and the myofibers and all that stuff.

Dr. Feltovich: Yeah, I think so. I probably haven’t read about this for two years now so I’m sort of searching my memory bank. But the bottom line is that we don’t know as much as we need to. But it is not the scary Dr. Google type thing that I think it used to be.

Dr. Fox: I mean, I think that…

Dr. Feltovich: Do you agree with that?

Dr. Fox: Yeah. I mean, essentially, it’s tough because the term, peripartum or postpartum cardiomyopathy basically means you get heart failure during or right after pregnancy. Thought to be somehow related to pregnancy. Exactly why that happens to some people and not other, we know risk factors but we don’t really get it, number one. Number one…

Dr. Feltovich: And is it an immune function? Is it an inflammation…yeah.

Dr. Fox: And also on top of that, like you said, there are probably people who had very mild forms of this where they just felt weak or short of breath and just let it ride and they never got an echocardiogram or a saw a cardiologist so never got diagnosed. Okay. And also people who have it, so it could be mild to severe, some recover, some don’t. And so, that was always part of it. We don’t know what’s going to happen.

Dr. Feltovich: We don’t know.

Dr. Fox: So I think that, like you said, the treatment of heart failure’s a little more advanced now than it was 5, 10, 20 years ago. And then, there is a recurrence risk and it tends to sort of, so different people feel differently about that, right. If there’s a recurrence risk and it’s more than zero, does that therefore mean someone shouldn’t get pregnant? Or does it have to be above 1%, above 2%, above 5%, above 10%, in order to this…there’s no right or wrong.

Dr. Feltovich: Now we’re back into how do you see risk.

Dr. Fox: Yeah. Exactly. So it’s very tough and we’ve known for awhile that people who recover, and recover quickly, when they get pregnant again, have greater odds of doing well than people who don’t recover or take a very long time to recover. And so, we sort of know that. So I guess a lot of it depends for you specifically, Sarah, about how long does it take to recover, what’s your function like and what will the risk be the next pregnancy, if you choose to have one. And some of that will be known and some of that will be unknown. And so, hopefully your doctors can give you at least brackets around that, like best case scenario, worst case scenario, what are the odds of those. And then, you could decide is that something you want to embark on or not. But there definitely is some risk. It’s just a matter of figuring out what the chances are, you know, how low is that risk versus how high is it.

Dr. Feltovich: I remember back then, and this has been 20 years, the cardiologist recommending to this patient that she never get pregnant again, even though at six months, she had normal function and was on no medications.

Dr. Fox: Yeah. Probably because the risk is…whatever it is, I don’t know the exact number. Let’s say it’s 1% to 2% and they’ll say, “That’s too high for us.” Right? And others may feel differently.

Dr. Feltovich: Well, they actually quoted her like a 50% risk. This was 20 years ago.

Dr. Fox: That’s probably all-comers, that’s not precision medicine, as we say.

Dr. Feltovich: It’s not. Yeah. And today, it’s very different. Because I had a patient with postpartum cardiomyopathy three years ago and the counseling was entirely different. Less than 5% risk. So she was just this patient who had recovered, less than 5% risk of recurrence. Those are very different things. So the science is progressing.

Dr. Fox: Very nice. All right. Helen, thank you for answering mailbag. You rocked it. Good job.

Dr. Feltovich: This was so fun, Natey. When can I come back?

Dr. Fox: We’re gonna do it. You’re coming back. We’ll schedule it.

Dr. Feltovich: I can’t wait.

Dr. Fox: All right.

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